USAID/Madagascar Partnership Empowers Community Health Volunteers

USAID/Madagascar and Community HealthVolunteers:Working in Partnership to Achieve Health Goals 7
CHVs sell them at a highly subsidized price in their
communities. However, it is a continuing challenge to
bring these products to CHVs and to their clients
who live in very remote communities. Hovercrafts
are providing an innovative way to assist CHVs to
meet this challenge (see text box next page).
COMMuNITy ENgagEMENT
Community engagement has always been at the
core of the USAID-funded health, nutrition, and
WASH programs in Madagascar. Given that the
Santénet2, MAHEFA, and MIKOLO projects have
focused on reaching populations in remote rural
areas, involving communities to take control of their
health needs has been critical to their success. In
addition, in a cross-sectional study, CHVs reported
that official recognition in their communities was an
important benefit in their work.
Beginning with the Santénet2 project, the Kaominina
Mendrika Salama (KMS) approach— developing
certified champion communes that reach agreed-
upon health indicators—has been used to empower
communities and make health services accountable
(see text box). KMS seeks to strengthen participa-
tory community development by: 1) setting up an
organizational framework that includes establishing
a social development committee in each community,
and 2) building the capacity of local leaders.
Operating alone and often disconnected from of-
ficial health facilities, it is not easy for CHVs to do
their work. However, the Santénet2 Project’s partici-
patory community-based approach provided them
with significant support, successfully building healthi-
er communities by working in concert with commu-
nity members.With this approach, the community
was included in all decision-making processes. For
example, in the 800 communes where Santénet2
worked, 11,483 community evaluation meetings
were organized from 2010 to 2012, to allow benefi-
ciaries to express their health needs.
The follow-on project to Santénet2, MAHEFA, uses
an adapted version, KMSm (Champion Communes
for Health), to give CHVs purpose and direction; it
continues to reap positive results.Through KMSm,
CHVs are connected to local health committees
(COSANs) and go through a process of health
planning, self-monitoring, and community-level evalu-
ations. MAHEFA’s Regional Director for Menabe,
Dr. Echah Mady, explained:“KMSm is about team-
work.Through periodic coordination meetings
between us, NGO partners, COSAN members, and
CHVs, we exchange experiences, boost commit-
ment, share performances, identify bottlenecks, and
adopt new strategies.”
A
Robin Erninesy, bicycle ambulance driver in
bemanonga Community, Menabe Region.
.dnommaHnibboR:tiderCegamI

8 USAID/Madagascar and Community HealthVolunteers:Working in Partnership to Achieve Health Goals
U
A quantitative evaluation conducted to measure
the intervention’s impact found very positive
results. By the final evaluation, all the CHVs in
the seven pilot communes had been resupplied
and stockouts at the CHV level were dramatically
reduced.The number of family planning users in
the pilot district was more than three times that
of the comparison district. Likewise, the number
of children with fever who were treated within 24
hours in the pilot district was double that of the
comparison district.The quarterly hovercraft deliv-
ery to the two most difficult-to-reach communes
served approximately 16,800 women of reproduc-
tive age and 11,200 children under five years of
age who would otherwise had no access to basic
health services
.tcejorPOLOKIM,ajnaF:tidercegamI
Using the KMSm process, as of September 2014,
275 (out of 279) communes had achieved champion
status; 983 fokontany had completed the community
scorecard process to measure client and commu-
nity satisfaction, and about 75% of users reported
being satisfied with CHV service quality.There were
21,099 members enrolled in a community health in-
surance program in 23 communes, and 181 commit-
tee members trained in community health insurance
management.
The MAHEFA Project has expanded the reach of
CHVs in the process of improving local communi-
ties’ access to health, water, and sanitation products
and services; its approach goes beyond identifying
and training CHVs to ensure that each CHV has a
commune-level Technicien Accompagnateur (accom-
panying technician) and Point d’Approvisionnement
(supply point) to ensure close support and access
to products.The core health services are comple-
mented not only by the behavior change and quality
improvement services, but also by transport, com-
munity health insurance, and community engagement
activities to allow people work together to address
a variety of challenges and achieve better health.
Continuing on the path begun by Santénet2 and fol-
lowed by MAHEFA, the MIKOLO Project works in
6 of Madagascar’s 22 regions, reaching a population
of about 5.5 million.The project initially conducted
a situational analysis to identify the state of com-
munity health services. CHVs were found to be
present and providing a limited number of services.
However, they had not had refresher training in
.tcejorPOLOKIM,ajnaF:tiderCegamI
Children in Talata Ampano take up the hand-
washing habit.

A
Using the Certified Champion Communes
approach to Make health Services accessible
to all
To apply the KMS approach, Santénet2 contracted
with 16 implementing partners—3 international orga-
nizations and 13 local NGOs.The KMS approach puts
communities at the center of a process for assessing
needs and planning, and implementing interventions
to improve community health.The Community Led
Quality Management (CLQM) system was developed
and embedded in the KMS approach, establishing a
large-scale CHV training strategy that is associated
with the creation of supervisory teams to support
communities and CHVs.The approach also included
the “learning for performance” methodology to con-
duct participatory planning at the community level.
a Champion CommuneTakes health Matters
into its Own hands
Located along theTsiribihina River, theTsimafana
commune, population 10,000, is often wet and
flooded. Hanta Marie Hélène, a CHV trained in 2011,
explained:“In 2012 my baby girl often had high fever,
as did many other children in my village. I think it was
malaria, but I could not be sure. I wanted to help her
and other mothers, but did not know how.”
MAHEFA launched the champion communes ap-
proach inTsimafana in June 2012.A year later,Tsimafa-
na became a certified community.Through regular
reviews with its partner NGO, MAHEFA found that
all CHVs had largely achieved their targets, which are
based on population size and demographic statistics
provided by the Ministry of Health.As of September
2013, health workers were able to reach over 4,000
men and women with awareness raising on malaria,
WASH, and nutrition.
The statistics say it all: 1,200 children diagnosed with
fever have been tested for malaria inTsimafana, out of
which 80% tested positively and were treated.Thanks
to the supply point put in place that sells anti-malaria
medication, CHVs were able to access and prescribe
the medication to children and infants diagnosed with
malaria.
CHVs inTsimafana are now connected to locally
define the commune’s goals for improving health.“We
were able to avoid a malaria outbreak,” a CHV stated
at the official certification ceremony. Dr. Echah Mady
added,“by connecting CHVs to other actors and
restoring the culture of target-based performance, we
have been able to record champion results.”
Members of a water users association in front of a well
built in MAHEFA Melaky.
ImageCredit:A.Ramadany.
ImageCredit:MAHEFAProject.
several years. Consequently, to ensure provision of
community-based health services in areas located
at more than 5 km from the nearest health center,
MIKOLO conducted refresher training with 4,489
CHVs.To motivate the CHVs and the community
to improve their living conditions and invest in
their health needs, the project established the SILC,
a community-based savings and loan system, de-
scribed later in this report.The project’s approach is
strengthening CHV skills, knowledge, tools, and mo-
A CHV counsels mothers in a hut, besalamp
district, Melaky region.

tivation to provide health services that comply with
quality standards and behavior change messages.
youth peer Education
All three projects integrated youth peer education
as part of their community outreach strategies,
often connecting youth to the CHV services. Under
the MAHEFA Project, for example, a key part of
the youth approach is linking youth peer educators
(YPEs) with CHVs in their communes who are also
trained in providing services to youth, including
family planning/reproductive health methods and
counseling.This linkage provides a foundation for
YPEs to refer youth needing services to CHVs, as
well as being able to refer them to CSbs.
The midterm evaluation of the MAHEFA Project
reported outcomes that included fewer childhood
illnesses and greater uptake of family planning,
more vaccinations, and more people practicing
good hygiene.
A MIKOLO Project goal is to include young people
in decision making about their health. CHV train-
ers are trained in modules that include a youth
approach.As part of this strategy, the project trained
ImageCredit:Juliette.
A youth peer educator conducting a home visit
inVohemar district, SAVA region.
ImageCredit:MIKOLOProject.
114YPEs in 19
communes in youth
and adolescent
reproductive health
in 2014, with the
goal of empowering
them to set up and
lead youth groups.
Similarly, the project
trained 111 women
leaders to set up
groups of model
women.
SuSTaINaBIlITy
Achieving program sustainability after USAID fund-
ing ends is a continuing issue in development, how-
ever, Santénet2 established systems and procedures
that continued to flourish even after its USAID
funding ceased.
From 2007 to 2013,USAID/Madagascar’s Santénet2
project equipped and trained about 11,200 CHVs in
rural and remote villages of Madagascar.Remarkably,
nine months following the end of the project,CHVs
continued to provide services and demand for these
services continues to increase.The Santénet2 final
evaluation found that 90% of women of reproductive
age in the former project areas reported receiving at
least one service from a CHV.This evidence high-
lights the sustainability of USAID’s community health
programs.The CHVs are continuing to provide ser-
vices in areas where USAID support has ended but
where health commodities are still made available.
In a spirit of mutual respect, Santénet2 and its
partners collaborated with communities to identify,
recruit, and train CHVs.The communities played a
critical role in CHV program sustainability.The com-
munity’s involvement, as well as their ongoing sup-
port of CHVs, contributed to the proper operation
and sustainability of community services. Santénet2
trained and supported two CHVs per fokontany—a
Mother Health CHV and a Child Health CHV—and
helped find replacements in the case of dropouts.
CHV and child.

CHVs served as an important link between the
villagers and their health center (CSb).As a result,
the project not only had an impact on the health
sector, but its influence was also felt in the over-
all community development and the welfare of
families.
Following in the footsteps of Santénet2, the
MAHEFA and MIKOLO projects are showing
positive results. In the December 2014 MAHEFA
midterm evaluation, CHVs noted positive health
outcomes as a result of the sensitizations they
conducted in their communities in all but one
focus group discussion. Outcomes included fewer
childhood illnesses, greater uptake of family plan-
ning, more vaccinations, and more people practic-
ing good hygiene. Messages regarding maternal and
child health and family planning resonated more
strongly with the community, whileWASH topics
were more difficult to convey in a manner that
made changes in the population’s activities.The
CHVs’ ongoing practical training has strengthened
their skills in family planning and reproductive
health; the impact can be seen in the increased
number of clients in these areas.
The mayors of communes were very positive
about the MAHEFA Project’s impact and noted
many positive outcomes, including the proximity of
CHVs for people seeking care, affordable drugs and
medications, a move away from traditional medicine,
better data on health events, better sanitation, and
decreased morbidity. Interviews with CSb directors
revealed a broad appreciation for the sensitization
work that the CHVs carried out. Community mem-
bers readily seek out CHV assistance before they
become very ill because of the CHVs’ proximity to
the community and their expertise, increasing the
likelihood of positive health effects.
When the MIKOLO Project began in 2013, it was
charged with rapidly resuming community–based
service provision of primary health care services
in its first year.When these activities resumed in
March 2014, almost 5,000 people—local authorities,
religious and traditional leaders, and representatives
of various associations working in the communes—
participated in the commune-led advocacy meetings,
underscoring the strength of the communities
and their interest in promoting positive health
outcomes.The MIKOLO Project’s 2014 situational
analysis of 375 communes in Madagascar found
that almost all of the CHVs interviewed were still
providing services and wanted to continue to do
so; more than 70% still had commodities on hand.
This evidence further highlights the sustainability of
USAID’s community health programs.
ChVs areWorking with Families to promote
positive Behavior Change
In 2014, in the Morafeno fokontany in the rural com-
mune of Fanambana, a CHV encouraged a young couple,
André and Anicette, who had three children, to become
a Care Group couple.A Care Group household must
“adopt” a minimum of three families with whom they
work for at least a month to encourage positive behavior
change.André and Anicette were using a family plan-
ning product and began to work with couples from nine
households who then adopted a family planning method.
Currently they are working with another five families
to overcome their barriers and emphasize the benefits
they have seen in their own lives:“improved quality of life
and improved physical condition for the woman.”This
approach continues to have a “snowball” effect in André
and Anicette’s community.
The chance of sustaining project-facilitated health improve-
ments is greatest when local system actors have sufficient
capacity and viability to carry out the key tasks needed to
produce key health outcomes within an enabling environ-
ment.
Sarriot et al. 2008.

A
At 56, Sabotsy Florine seems younger than her age. She is an important leader in
promoting health in the fokontany of bonaka in eastern Madagascar and a key
reason why her services have continued since 2007.The community elected
Florine to be a CHV because of her friendly and helpful character. She has been
the mother community agent since 2007 and took courses on community worker
services for children in 2009. Florine was also one of the 4,330 community
workers who received cross-training by the MIKOLO Project in June 2014 to
upgrade their skills into full-service CHVs.This training upgraded CHVs’ knowl-
edge and their capacity to be a polyvalent CHV (that is, able to treat childhood illnesses and provide
counseling and contraceptives to women of reproductive age).
With this training,Florine is better equipped and truly committed to meet the health needs of the
people of bonaka and in the larger commune.People come to see her from other towns.She has the
respect and confidence from the head of the CSB because of her professionalism and performance.She
follows 50 regular family planning users and receives a new client each month,higher than the CHV
monthly average of 32 regular users.The community is grateful for her services.
“I love what I do even if I do it voluntarily. My greatest joy is to see people healed and healthy thanks
to my small contributions,” Sabotsy Florine said smiling. Her activities are not limited to consultations.
She also organizes awareness sessions on hygiene and sanitation issues, family planning, seasonal topics,
and vaccinations. Sessions are organized through home visits, group discussions, and public meetings.
Florine takes these activities to heart because she knows their importance.“To all the CHVs, let’s be
trustworthy. Greet people with smiles if you want to succeed and help others,” says Florine.

ChallENgESImageCredit:TahianaAndriantsoa.
R
egional coordinators noted that the
capacity to manage stock varies among the
CHVs and that occasional stockouts occur.
The MIKOLO Project is addressing this problem by
establishing a SILC that will provide funding to keep
medicines in stock.The strategy is to train SILC
technicians who will identify and train field agents
who will, in turn help establish SILCs in the com-
munities. However, a group of CHVs recently came
together on their own initiative to form a SILC to
raise funds for local medicines.
CHVs also face issues involving motivation, supervi-
sion, training, referral systems, and compensation;
they must ensure cultural sensitivity and good com-
munity relations, and coordinate program and health
system efforts as well as address sudden political
crises.The MIKOLO Project is addressing many of
these challenges in its approach, providing enhanced
group and increased on-site supervision, quarterly
data reviews, evaluation and certification of CHVs,
and introducing CHV peer supervisors.
Another major hurdle that CHVs confront in their
efforts to promote better hygiene and sanitation are
deeply entrenched social norms that are resistant
to change, particularly those related to water and
sanitation—such as eliminating open defecation,
promoting latrine construction, and making hand-
washing a routine exercise.To help make these
important social changes, CHVs are involved in
Mutuelle de Santé members meeting in
bobatsirevo community, SAVA Region.
ChVs Build a SIlC to Ensure the local
availability of Medicine
In beravy Haut fokontany, 7 km from the main road,
in the southern part of Madagascar, CHVs are help-
ing their communities to ensure medicines remain
available and improve their health.To satisfy demand,
the CHVs founded the AC MIRAY group as part of the
SILC.The AC MIRAY group was created by 18 CHVs,
including 6 women and 12 men, following the refresher
training that the MIKOLO Project provided.The group
follows the SILC standards and was acknowledged by
the CCDS.A SILC technician helped the members
form the group.The group began organizing the savings
account through the frequent meetings that they orga-
nize for members, with credit beginning in late 2014.
For CHVs, being in an AC MIRAY group is an oppor-
tunity to create a fundraising activity as most of them
work as volunteers or in farming.The SILC is also
a way to assist CHVs so that they can sustain their
health products and avoid stockouts.
According to the implementing NGO’s technician, this
SILC was not supposed to be in place just one year
after the program began. Despite the long distance
between the CHV sites, the CHVs proved that it is
possible to achieve good results as long as there is
good will, community commitment, and dedication.

ImageCredit:RobbinHammond.
CHV Helena measures the mid-upper arm
circumference of Angeline’s son, bemanonga
Community, Menabe Region.
Community-ledTotal Sanitation (CLTS), which was
launched in Madagascar in 2000.This remarkably
successful approach catalyzes communities to con-
struct unsubsidized latrines and improve handwash-
ing practices. Social pressure, mutual support, and
appropriate local solutions lead to greater owner-
ship and sustainability. Once all households have a
latrine, the community is recognized with an open
defecation-free (ODF) certification. Initially, however,
many of the newly built latrines did not meet the
definition of an improved latrine, thus increasing
the risk that it might not be maintained. Now CLTS
is linked to the construction and sale of low-cost,
washable, hygienic latrine floor slabs. Local masons
are trained to produce and market the slabs, and
village savings and loan associations are established
to generate capital so community members can
purchase the slabs. CHVs also support theWASH
activities through information, education and com-
munication activities, and materials such as posters
that promote keyWASH messages.
Making a difference inWater, health,
and Sanitation
Working with the communities, 1,169 local
CLTS facilitators (also volunteers) were
trained by MAHEFA-supported CLTS train-
ers who conducted 710 triggering events
in six regions.As a result of these events, a
total of 3,621 latrines were constructed, of
which 247 are improved latrines with wash-
able slabs.There were 76 sites that were
self-declared ODF and 3 of which officially
declared ODF by a regional committee in
Menabe Region.
Working with the MAHEFA Project, a local
women’s group ensured that all 102 house-
holds would have access to a latrine; now
there are three latrines for each household.
Handwashing stations are widely visible.The
community is clean and proud of it.

lESSONS lEarNEd aNd NExT STEpS
C
HVs in Madagascar face many challenges
but since 2008, the three USAID-funded
projects have helped them to improve their
service delivery, grow in numbers, extend their
reach, involve and empower community members,
and ultimately, bring positive changes to the health
and welfare of many Malagasy people.
To move forward and continue in this upward trek,
lessons learned from the projects can help inform
next steps:
• ChV support programs were found to be
strongest in recruitment, initial training, com-
munity involvement, advancement opportunities,
and documentation and information manage-
ment. Future efforts should seek to sustain
these strengths and address identified weak-
nesses in equipment and supplies, individual
performance appraisal, and country ownership.
Filling these gaps presents opportunities for
shared learning, greater coordination between
stakeholders, and the application of improved
methods to develop and test interventions to
address programmatic weaknesses and improve
the effectiveness and sustainability of CHV
programs.
• Ongoing trainings should continue to build
skills among CHVs, not only around service
delivery, but also in supply chain management
and using effective ordering procedures as a
mechanism to reduce the number and duration
of stockouts. In addition, other factors affecting
the supply chain should be addressed—such
as ensuring the presence of supplies in central
stores and optimizing mechanisms for trans-
porting supplies to CHVs. Lessons may also be
gleaned from experiences in other countries.
linkages with the formal health system at
all levels should be strengthened, including those
with respect to the referral system.Training
should be conducted, with CHVs encouraged
to refer clients in need of services to the
health system. Health system providers should
also be trained to provide counter-referrals
to ensure continuity of care and follow-up
for their clients. Other forms of more direct
communication could also be developed and
supported to enhance the links between CHVs
and health facilities.
•Lessons
ImageCredit:FanjaS.,MIKOLOProject.
In June 2015, 10 CHVs in the Ambalakely rural
commune were certified during a ceremony
attended by U.S.Ambassador RobertYamate.

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CHV and child.
A 2011 Santénet2 /IntraHealth report examining CHV
training and support praised the role of CHVs and the
community in improving health, stating:“…the commu-
nity seems to show a strong commitment, and CHVs
serve as an important link between the villagers and
their CSb.”
Front cover: CHV and youth peer educators
conducting education on family planning methods
in Soamahavelo Fokontany, Menabe Region.
Image credit: Robbin Hammond.
Writer: DinaTowbin
Design and Layout: IbI
Produced for USAID/Madagascar under Global
Health Program Cycle Improvement Project
(GH Pro) Contract No.AID-OAA-C-14-00067.

Tel. 261 20 23 480 00/01—Fax 261 20 23 480 44
website: https://www.usaid.gov
facebook: https://www.facebook.com/usaidmadagascar
November 2015

USAID/Madagascar Partnership Empowers Community Health Volunteers

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